Physician to CEO: Dr. Antonio Gamboa on the Power of Business in Medicine (part 1)

That at the end of the day, and I say this a lot, we, the physicians, have the power of the pen. Nothing gets paid. Nothing gets paid unless you are or somebody else that's a doctor signs off on it, and that includes a hospital.

Hi, everybody, and welcome to the podcast. This is Generations md. My name is Stephanie, and I'm joined here by my colleague, Dr. Sarah Davis, who's also my mother. And today we have a very special guest. Please welcome to the podcast, Dr. Gamboa. Hey, welcome.

Thanks for having me.

Yeah, we're so excited to have you and talk to you. We were just talking a little bit before about the connection that we have. My dad has business relationship and friendship with Dr. Gamboa, so he was kind of getting into how they met and. Yeah, but backing up before that. Can you talk a little bit about just how you got into medicine?

Yeah. So I grew up in El Paso, you know, which is. I said true West Texas, and, you know, was born and raised in El Paso. I was born to immigrant parents from Mexico. My parents were actually, you know, I would say, not very well educated. They didn't have the opportunities they afforded me by, you know, making the trek that they did here. But, you know, I've always told people that the lack of education didn't mean that they were not very smart, because I consider them incredibly smart, obviously very hardworking. And I think a lot of the lessons I learned from growing up in a first generation in border town, both first generation American citizen and border town, are largely related to my ambitions to do well, to help others, which ultimately led me into medicine. And also, frankly, when you come from nothing in terms of financially, because I believe I had everything as it pertains to family, but when you come from nothing financially, you tend to be a little more comfortable with risk taking. I think ultimately my. My path had evolved from being a physician to being an entrepreneur in healthcare, I think is very directly related to that. I talk about it a lot amongst friends circles and interactions, you know, when people ask me about my background. And it's something I'm very proud of, and it's something that, you know, I. I will actually also say that I have an advantage over many people. And that sense that I was sculpted, you know, in terms of risk tolerance and my vision for how the world works was, you know, largely informed by struggle and, you know, ultimately blessed by success because I've overachieved at every stage. And I think that's generally my personality. Right. Firstborn generation, first to go to college, from all My family certainly going to med school was even that much more difficult. And then having the fortune of starting growing and eventually having, you know, financial success in a business all has been, you know, I feel incredibly fortunate, but obviously I know that it's not all lucky. There's a lot of hard work there and a lot of dedication to it and you know, some, a few God given talents and just enough intelligence that I was able to achieve what I, what I did achieve in medicine and beyond. But, you know, that's, that's very much kind of what my DNA is.

Yeah, I think that's so interesting. You talk about being like less risk adverse. I think a lot of people that go into medicine. It's kind of weird talking about this last week on the podcast a little bit just how I feel like a lot of people go into it because it is stable and you kind of just put one foot in front of the other and follow the path. Get into med school, go to med school, get into residency and there's not so many alternative paths that you can take and, you know, like it. The end goal is to be a doctor and if you do this, this and this, you can do it. Did you know kind of this about your personality before going into med school or kind of. It sounds like you have more of this entrepreneur, risk taking business mindset. How did that kind of lead you to choosing medicine before kind of going on and doing this entrepreneurial stuff?

Yeah, I don't know that they're necessarily that one caused the other. I would say, you know, the being a physician and being afforded the, the stability, you know, a very good income actually help my entrepreneurial side blossom. So why I got into medicine was more related to experience. And you know, I've spoken about this before with friends and family and it's, you know, I did not grow up with healthcare. We couldn't afford healthcare. And so, you know, I recognize the struggles of people in my community. Fortunately, we were pretty healthy, so it's really rare. I think, you know, main thing I struggled with was some ear infection growing up and some minor, minor issues. I had my tonsils pulled down when I was five, you know, and we managed through that somehow, you know, without insurance. But, you know, ultimately it was noticing the struggle of people that did not have healthcare that really inspired me to, you know, pursue medicine. I started writing little stories at age 8, you know, initially pictures at age 5 about me being a doctor and helping others. And my mom reminds me of that all the time because my memories are a little bit Hazy at that time. But she says, hey, you knew you wanted to be a doctor when you were little. And that just kept getting reinforced in terms of my experience and my passion and how I saw myself helping others. My initial vision was that I would go to med school, would set up a classic primary care practice and know my patients for 40 years. It's a very long story you probably won't have time to get into. But ultimately the reality is that, that healthcare has evolved over time such that it's difficult, you know, for, for any of us to achieve that dream independently. And so, you know, opportunities eventually arose where, because I wanted to start paying off my debt and I didn't have any financial means with which to extend or take on additional debt, you know, I went straight into hospitalist medicine, which was overnight from being a resident and earning, you know, 38,000 a year to, you know, 4x 150,000 a year. At that time, 22,005 was incredible, right? Like, I was like, wow, overnight, you know, I've gone from being really poor, not too rich, but you know, to, oh, I can afford a nice place, I can buy new furniture, I can get a flat screen tv. But anyhow, you know, I kind of, I'm all over the place on this. But you know, healthcare was always, you know, my vision and my, my mission and my passion. It still is, but over time that, that creative, risk tolerant, ambitious, and frankly, a little bit of resistance to authority. That comes from being, you know, somebody who grew up in the environment I grew up in. I was not complacent with just being a doctor, which sounds kind of, you know, arrogant because I was very fortunate to, you know, got my medical degree and, and I, I believe I was a very good physician at the top of my game in hospitalist medicine when I started a business. But you know, my dad always used to tell me, you know, keep in mind, my dad was, he was a server waiter, you know, for all his life as, as long as I knew him, worked two or three jobs at a time, was incredibly proud of me, but would tell me, don't just be a doctor, you know, be more. Those things eventually sort of blossomed over time and, and I realized only now how my risk tolerance and my, my willingness to take, you know, an adventure in healthcare into business was a reflection of my past. But, you know, my mission and my passion for medicine never really changed.

Can you just sort of walk us through that a little bit of like how, how that happened? So you did your residency in internal med Med.

Peace I was internal medicine. Okay. Yeah.

Wait, can you just briefly, why did you choose med Petes?

I knew I wanted to be a primary care physician that without a doubt hated surgery, absolutely abhorred ob. Oh. You know, it was what drew me, the sort of the scientific approach, solving problems, you know, academically. It was what interested me to, to, to take on a, you know, a healthcare field that had a lot of variety. And so the, the challenge was I like pediatrics as much as I like medicine and I could either become a family medicine doc. And I always say this, and I mean no disrespect, family. I didn't want to waste my time in OBN in surgery. So, you know, I found out there was a program that was med peds. And I said, that's me. Right. And I didn't, I didn't necessarily know that I was going to commit to one side or the other. I ended up committing primarily in internal medicine, like many of us do, unfortunately. But the reason I did medpeace is because I, I, you know, both of those fields to me were academically attractive. And it was a, it was a, you know, figure it out and detective work on physiology, pathology and of course, the impact that you can make to people from, from their birth to, you know, to the grave. That was really attractive to me from a personal level. Yeah.

Well, let's talk about that pivot when you're working as a hospitalist and then kind of moving towards this business entrepreneur side. What did that look like?

I'll take a step back. I was a hospitalist initially. I got hired by the same doctors that trained me and, you know, said, hey, there's this hospital, we need staff, you know, we really like to do in residency. Would you consider coming to work for us? And it was an easy yes because I liked the people that trained me. They were great mentors. I worked as a hospitalist initially for them for a couple years, and then I went to work independently for a couple years and then I eventually landed in a kind of de novo hospitalist owned medical group. And all three of those experiences while still in hospitalism were very different from each other. What I realized that in the first hospital I worked in, it was literally me and two other hospitalists and, you know, we, it was a small hospital and I call it my extended residency because I did probably more procedures and more intensive care, more intubations, chest tubes, everything. We did not have really good critical care. And keep in mind, this is downtown Phoenix. I wasn't, I was not in a remote Area. It was just in a bad part of town that nobody wanted to work in. Downtown, 7th Street, 7th Avenue in Phoenix. And, you know, being bilingual was super helpful with that. But anyhow, I did that and I felt very confident. My skills just dramatically improved as a physician. So I, you know, I worked independently and I was highly sought after by every group. I would cover shifts. I started realizing I could make more money, frankly, independently than I could as an employee physician. Then that sort of eventually landed me in this hospitalist role as a de noble physician, which was much better paid. You know, I took like a $20,000 increase at that point. $180,000 was a lot of money, you know, 2008 or 9, whatever that was. But, you know, what I realized is that it was an easy job. Was actually ridiculous that they were paying me that much to sit in the hospital, do almost nothing because I had a great reputation. When I did see patients, obviously my outcomes were good, but I was really dissatisfied. And I didn't see myself happy in a position of this kind of glorified resident, frankly, in terms of, no offense to you, Stephanie, but I was admitting for cardiologists and surgeons and kind of doing the tuck ins, which were easy because I was in an affluent part of town and everybody had insurance, so, you know, fewer chronicle conditions, chronic conditions, sorry. And anyhow, it was then that I realized that I wasn't going to be happy unless I was part of something, A true part of something. So a partner. And so I started looking for opportunities. At that time I was about getting married, you know, got married in 2008. My wife and I, you know, were fortunate to, you know, get pregnant. 2009, Phoenix was growing then. Didn't feel like home. I wanted to come back to Texas, but it was important that I came back to an opportunity where I could be a partner. So came back to Texas to join a small independent group, actually medium sized independent group, about 40, 50 hospitalists. And they had a partnership track. After a couple years, you could buy into partnership. And that was really important to me. As I began that partnership and finished my two years, I immediately started saying, hey guys, I want to do more. I want to be, you know, on the board. I want to put my hand in the, my name and the hat for leadership. You know, what can I do to help promote the well being of this, of this group in this business? You know, I was the chief of staff for medicine at the hospital. I was the assistant to, you know, the chief medical officer for quality. And I was in every committee for free that I could join. But I, I wanted to do more. And ironically, the existing leadership, I guess didn't, didn't think that such a junior partner should have that opportunity. So what happened was I started looking for entrepreneurial opportunities outside of the hospital. And that's how I landed doing nursing home business and a nursing home practice and post acute in general. It was related to my ambition to, you know, provide leadership and, and you know, develop a business that took me to do something on the side because unfortunately for them, they didn't give me an opportunity to help lead their business into, you know, a better place.

Wow, that's so short sighted.

Yeah, you know, I like to think so, maybe they don't feel that way, but they don't know they no longer exist and I've done pretty damn well. So I think it was short sighted and yeah, so, but that's how, that's how it started, you know, and even that entrepreneurial, like when I started the business, I just was looking for another way to kind of be my own boss since I couldn't contribute to leadership in the existing group or wasn't allowed to. And then eventually it took a life of its own. It was my commitment to providing great care, my confidence that I developed early on, right. Doing procedures and taking care of really sick people in the hospital in Phoenix. That translate into my ability to say to the nursing homes who at the time, the standard of care in nursing home was incredibly poor by every standard, and including physician engagement, there was none. The standard of care was a doctor would come once a month, they do bedside rounds or, you know, doorframe rounds, write two notes, leave it in the chart, maybe look at medications, sign all the documents that they needed to sign from regulatory standpoint, and they'd be out the door, right? There were lunchtime medical director, they were not really engaged in taking care of people. And as a result of that, there was a lot of, a lot of people coming back from nursing goes into the hospital. I saw that. It's actually what initially prompted me to say, well, what's going on? Why I fix these people, I help them get better and then they're back in two weeks or a month, you know, there's something going on. And you know, I hesitantly took my first job as a medical director. And when I started showing up twice a week, they're like, what are you doing? I'm like, what do you mean this is the job. I know the people, I'm sending them to you, I'm taking care of them. Here, I don't want them to get sick again. Oh, well, every other doctor only comes once a month, and, you know, they're not writing as many orders, which, by the way, was a problem for them. And so I was like, well, this is the way you keep them. Well, this is how you keep them out of hospital. It was interesting, but it was an evolution in that first community. And I'm grateful that they saw the importance and the passion that I had to improve the care there, such that they went along with my vision as a medical director for that facility, which I took seriously. And I said, hey, we got to be able to put in IVs, we got to be able to do IV antibiotics, IV pushes. Not anything dramatic like ICU quality, but fluids, et cetera. And they trained several nurses on each shift. So when they call me with fever, instead of doing what every other post acute doctor would do, which is to cover their butts and send them right back to the hospital, I'd say, no, draw cultures, get a urine, give them a gram of rosephen, put an IV and give them some fluids, and call me if the blood pressure, certain parameters change, or mental status, anything clinical that would indicate that we're not able to turn this around in the facility. And I would go see him early the next day. And so this became my calling card. And this is the reason why the business grew because, you know, accidentally, I was developing a new standard of care and I recruited another physician. This all happened within months. Now I recruited another physician because I was getting too many facilities offered to me. I couldn't take care of them all and do a good job. So I said, I need more people to come help me. Recruited, you know, who has now been my partner for, you know, 15, 16 years. Doctor. And between her and I, you know, we just started growing the business. And this is, you know, about 2010 that the business starts officially with me filing on the Texas website an LLC that we called Elite Patient Care. I'm glad I. I talked about El Paso because the reason Elite Patient Care, EPC in short, was EPC was not because I thought we were elite, because I. I wanted to call out to my roots and I wanted to call it El Paso Care, but it sounded kind of dumb. So I said, okay, I'm going to keep the initials E.P. and what rhymes or what matches E. Elite Patient Care. Oh, perfect. So we call it Elite Patient Care. And we took off from there. We went from just me in Paula, two docs in a van, we often joked to hiring a first nurse practitioners. And this is sort of through 2012, we took the commitment of saying if we build it, the business will come. And we hired nurse practitioners at risk and gave them a base salary. But the expectation was they were in our facilities five days a week, eight hours a day, and making sure that our patients didn't decompensate. And that promoted our ability to really take care of everybody in the facility as opposed to just a few people. And that ended up being very good economically because it was much more efficient than what most post acute practices did, which was to pollinate 50 facilities, seeing three or four patients, as opposed to actually being on site, consistently delivering good care and at the same time growing the business opportunity. So we did that. You know, I'm proud of. That was sort of the initial step in the risk tolerance because we had to pay these people and we weren't sure if we were going to grow. But our gamble paid off and we were able to develop, you know, business, which grew very quickly.

Yeah, let's pause there because I do want to ask, did you have anybody early in your career that was like a mentor or somebody that you saw that was. Was doing this sort of thing? I. You just mentioned that, you know, right out of residency you were hired by the people that trained you. And I go to school at a big institution and I definitely, I'm experiencing academia a lot, I'm experiencing working for big hospital systems a lot. But the only reason that I really know about even independently contracted groups is because of my dad. This is. I talked to my friends about it and people in medical school, and no one is really even thinking about joining a group, let alone like creating their own. Did you see this or did you just kind of learn as you went?

Yeah, definitely the latter. Right. It was a trial by fire, you know, trial and error. Plenty of errors, trust me. But, you know, fortunately we were providing a good product enough that we would survive in our initial business mistakes. But eventually, to your point, actually in about 2012, I told my partner, so, Paula, we're getting kind of big. We have, you know, 15 people on payroll, which I thought was a lot. You know, and I'm like, these people depend on us. Their families depend on us. Their benefits can, you know, are provided by us. You know, if we're going to keep doing this, one of us has to take this business side seriously. And, and so, you know, I said, look, here's my proposal. I will go back and get my MBA if. If you pay for it, you know, if we. Our business Pays for it because it's not cheap to go to UT McCombs and get your MBA. So, you know, she said, okay. She said, let's do it. I went to McCombs between, you know, 2013 and 2015, got my MBA. It was an incredible experience for me in particular. And I talked to a lot of doctors that are looking to do their mba, by the way, sort of mid career or even sometimes early or late career. And I always tell them the same thing is what do you want from it? You know, do you want to actually deploy that knowledge in a way that will impact your current career or future or is it more that you're looking for those extra letters so you can sort of go up the corporate ladder? Nothing wrong with it. But my advice to them is that you don't need to do that. You know, that's too expensive and you're not going to get the benefit of it. And by the way, I see this all the time. You know, in my own cohort there were several physicians, chiropractors and other healthcare professionals and all of whom made good money and decided to go back and get this education for different reasons. In my particular case, it was to apply knowledge to growing business, which ended up being a perfect scenario because every time I learned something new in leadership or finance or accounting, I would literally go to Paula, Dr. Kejo and I would tell Apollo, we need to do this, we need to do that, we need to structure this and that. And you know, again, it was a real time impact for us in our growing business to gain that knowledge which, you know, was not innate or intuitive to us. It was very, very difficult initially in the business program which by the way, my daughter is a freshman in high school and like you want to become a physician, Stephanie. And I'm proud of that. I did not ask her to do that. In fact, might have tried to discourage her. I, you know, I, I told her and remain very committed to this. I don't want her to be pre med. I wanted to get an actual degree that, you know, things are a little longer before she gets accepted or faces challenges in the interim that she can actually have a career from. And so, you know, I'm coaching her to look at business or accounting or, you know, engineering something because you can always do your prereqs and you can always apply to med school, you know, and I, I believe pre med is a disservice to most students because you can't get a job unless you want to work like as a low level lab. Employee.

Yeah. No, I was actually just talking to a friend about this yesterday who's in law school, and she was saying how people, you know, go and have whole careers and then go to law school because you don't have to do all these prereqs. And I was thinking, and, you know, people in law school just seem a little more mature and like later in their life and versus my class in med school. We're all different ages, but it all seems like we're at the same level because nobody went. And there's. There's some outliers, but for the most part, nobody went and had a career before they went to med school. It was all just temporary. Exactly. Like MA jobs, lab jobs. Like, nobody start. Everyone was waiting to start their life, which, as you just said, is such a disservice to like, making us whole people.

Well, it's also kind of a problem because if you're pre med and then that's all you've got, and then you've got a lot riding on that acceptance to med school, and that causes a lot of anxiety and people. Because there's no, there's no real backup plan because there's not a lot you can do with a lot of those degrees.

You know, that's my position on it. I. I've been to. I was invited to several. It's been a minute since I've done it, but I used to go to UT all the time and talk to the, you know, pre med students at ut. And, you know, I was the one outlier. Everybody else on the panel would typically say, yeah, pre med this and that. And I said, nope, I'll do pre med. And then I give them my reasons for it. Right. And I think, you know, it's. I think it's an opinion, but I think it's a valid opinion because to your point, Stephanie, I think the challenges are that it is changing. I know there are schools, including Dell, for example, that I believe forces med students to choose a path of MD, MHA or MD mba, in which case, you know, they come more prepared to the world, to your point, with practical knowledge on how to be more than a physician and how to, you know, properly manage what will be, you know, disposable income in the sense of, you know, if you do things right, you know, and ultimately, I think there's a lot of room for tracks in education. And again, I do believe several medical schools are starting to make this mandatory to have students get some degree of, you know, a business and financial education so that they don't face challenges. It. It's incredible to me. And, and again, I'm sure you guys both know people like this, that their physicians are making good money, you know, six figures easily, and they're still living check to check or hand to mouth. And I think that's a reflection of a lack of it, of financial literacy and, and living beyond their means and kind of getting enamored with that jump from 50,000 to 250,000 that quickly gets them into trouble. And, you know, frankly, I hate to see docs working at 70 and still have debt. You know, it's incredible to me that that would happen, but it happens to us, and this is part of my mission. By the way, when people ask me all the time, why did you go to NBA? Two very particular reasons. One was, I want to learn about business because I had a business that I was growing and I wanted. I wanted to be responsible and do well by the people depending on me. To three reasons. The second reason was having been a member of several committees and board positions in the hospital as a hospitalist leader, not for my group, but for the hospital. I, you know, I saw the challenges of the communications, as I. As I term it, between the suits and the white coats. And it was frustrating to me that we were talking different languages. And, you know, I think both sides were intimidated by the other. You know, the quotes were intimidated by financial conversations and frankly, couldn't stand up to it because they didn't understand it. And then the suits were intimidated by the fact that at the end of the day, and I say this a lot, we, the physicians have the power of the pen. Nothing gets paid. Nothing gets paid unless you are or somebody else that's a doctor signs off on it, and that includes a hospital. I think that dynamic is largely negative. And so one of my goals was to be a translator and to be a mediator in that conversation, because I believe that every physician deserves to make quality living and that the word profit shouldn't be a dirty word. And while I believe in the sanctity of the Hippocratic oath and first do no harm, I mean, I've lived by those rules for all my life. I also think that it's ridiculous that somehow we should be assigned to martyrdom. And, you know, for all the sacrifices, the risk that we take, and frankly, the sacrifices we make along the way, personal family health, that we shouldn't be compensated well, I mean, that's ridiculous. I'm always a defender of the physician's right to be an owner, to be a leader and to be involved in key decisions at any level. And that's part of my mission. You know, that is ultimately what I feel I was brought to this Earth to do is to promote that independence and to help physicians capture most of the value that they've created in.

Hi, everyone. Stephanie here. So this episode with Dr. Gamboa was so good, we decided to split it up into two parts. So part two will be out next Wednesday, so stay tuned for that. In the meantime, you can find us on Instagram and TikTok @Generations. And if you have any questions or interested in being a guest on the podcast, you can email us ataskgenerations MD gmail.com and we will see you next week. Bye, guys.